Minor Surgical Procedures - How to document and bill

by  Codapedia
January 6th, 2016

By: Codapedia Editor (Dec/29/2015) 

When performing minor surgical procedures, it is important to document what was done, how it was done, where it was done, why it was done, how deep, how long, and how many.

In billing and reporting a procedure, document in the medical record the key components of the procedure as described by the CPT® book. If the CPT® book defines the code as centimeters, document how many centimeters long the lesion was. If the CPT® book defines the code as each, document how many. If it describes the depth, document the depth. Always document where on the body the procedure was performed.

There is no extra payment for supplies. The cost of supplies is included in the practice expense portion of the code and so is included in your payment.

Payment differs by place of service. The payment for the same CPT® code will be higher in an office (i.e. non-facility setting) than it will be in a facility,  (i.e. the hospital emergency department out-patient department or ambulatory surgical center).

Use caution in billing for both an office visit and a procedure on the same day. Review the rules related to Modifier 25 in Codapedia.

Always look at the full CPT® definition and don't rely on a small, abbreviated description on your encounter form. If there are procedures you perform that are not on the attached chart, look up the procedure in the index of the CPT® book, find the code in the numerical listing in the CPT® book, read the description, noting any editorial comments in the book, and document the criteria in the definition.

2009 RVUs for Minor Procedures (pdf)  


Minor Surgical Procedures - How to document and bill. (2016, January 6). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/minor-surgical-procedures-how-to-document-and-bill-28089.html

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